19th and 21st Centuries Underfunded and Underregulated American Mental Health System

This paper has the objective to explain how the 19th century underfunded and underregulated American mental health system still needs reform in the 21st century. In the 1840s, the abuse and inhumane treatment of mentally ill individuals placed in county jails, almshouses and private homes gave origin to actions directed towards the betterment of the system. Dorothea Dix (1843) in the “Memorial to the Massachusetts Legislature”, describes in details how inhumane treatment of the mentally ill occurred. She depicts females and males caged in almshouses, some in more comfortable situations than others; an individual who had been chained for 17 years; individuals incarcerated with criminals in county jails who were left unclothed and chained in the dark, without any heat or sanitation; individuals in private homes confined in closets, stalls and cellars due to the lack of support of their family members; individuals who were beaten with rods and lashed to obedience; and, county jails and almshouse improperly staffed. Overall, the author’s findings were clear, there was no therapeutic method being applied to treat those individuals and they were being abandoned, abused and neglect. Dix (1843) emphasized that while the usage of cages was very common and negligence a frequent occurrence, chaining people and willful abuses were less frequent than sufferings that originated from ignorance. In addition, she argued that it was also unjust to place convicts with insane persons since they were obligated to live with individuals screaming and shouting night and day. The social reformer presented the problems of abuse and inhumane treatment to the members of the Legislature of Massachusetts in a way that was coarse and severe, “The condition of human beings, reduced to the extreme states of degradation and misery cannot be exhibited in a softened language, or adorn a polished page.”

Social Reformers as Change Agents

Dorothea Dix was a social reformer who vehemently advocated for the mentally ill. In the “Memorial to the Massachusetts Legislature” (1843), Dix appealed to the members of the legislature,

I come as the advocate of helpless, forgotten, insane, and idiotic men and women; of beings sunk to a condition from which the most unconcerned would start with real horror; of beings, wretched in our prisons, and more wretched in our almshouses.

Interestingly, according to Barusch (2014), it was due to a Sunday school class at a jail outside Boston, that the social reformer became aware that the insane were housed with criminals and were victims of all sorts of abuse (p.227). Her indignation at such situation stimulated her career in social advocacy. From 1841 to 1842, she investigated the jails, almshouses and even the streets and private homes across the State of Massachusetts. Her methodology consisted of visiting jails and almshouses, observing the treatment and living conditions of the insane housed in them, and preparing a petition containing her findings to the members of the Legislature of Massachusetts. After Massachusetts, the mental health reformer continued her work in other states and encouraged state legislatures to expand and establish mental health institutions. Throughout Dix’s career, she was essential for the foundation and/or expansion of 31 asylums for people with mental illness. Barusch (2014) further explains how Dix responded to inhumane treatment. Like many other advocates, she used exaggeration or hyperbole during her presentations. The author compares Dix and her fellow reformer Samuel Gridley Howe, as both used dramatic presentations to convey the urgency of the matter they were advocating for. On the other hand, while Howe attributed the roots of insanity to failed social institutions, that is, insanity was caused by society, therefore, it should be responsible for the care of its victims; Dix postulated that the causes of insanity were irrelevant and argued for the moral necessity of protecting the insane from the “predatory forces of society” (p.228). In other words, Dix was not concerned about the roots of insanity, but on how to solve the problem of inhumane treatment of the mentally ill. Parry (2006), in the article “Dorothea Dix”, clarifies how the social reformer supported the model of care of “Moral Treatment” founded by William Tuke in England and Phillipe Pinel in France. Based on that finding, it is inferable that Dix´s conceptualization and critical analysis of inhumane and harsh conditions in the prisons and almshouses was strongly influenced by the “Moral Treatment” approach.

Past and current social workers’ responses to the inhumane treatment of the mentally ill. Although social advocates throughout the history have fought for the betterment of the American mental health system, different versions of abuse and inhumane treatment continue to happen in the modern American prisons. If in the 1800s therapeutic treatments were basically nonexistent, nowadays, although they exist, many individuals don’t have access to them. For instance, according to Mental Health America, in its 2017 report, 56% of American adults with a mental illness did not receive treatment; and Arkansas, Mississippi and Alabama have over 57,000 people with mental health conditions in jail and prison (http://www.mentalhealthamerica.net/issues/state-mental-health-america ). Early in our history, social reformers responded to this issue through investigation, observation, and advocacy. They exposed the atrocities practiced in the jails and almshouses and petitioned their state legislatures for reforms. Nowadays, as much as social workers, counselors and other mental health professionals want to report abuse, they are often coerced to remain in silence by correction officers and other jail staff. A disheartening example is the Dade Correctional Institution, in Florida, in which the Staff Counselor Harriet Krzykowski witnessed mental ill inmates being abused and neglected. Inhumane treatment has happened in the form of starvation, sexual assault, seclusion, torture, badgering, and even murder. According to Krzykowski, her attempts to advocate were silenced by the fear of corrections officers and her superiors. Using human rights as a framework for this analysis, one can realize how the Florida Department of Corrections fails to provide a safe place for mental health treatment inside the jails, which results in not only the inmates’ human rights violation, but also in the violation of the counselors’ rights. One can observe how power relations are prevalent; as Krzykowski affirms, “I kept getting the message that whatever security says, goes”. Although in May, 2015, a senior adviser at Human Rights Watch released a report about physical maltreatment against inmates with mental disorders in American prisons; there is a “it’s none of our business culture,” which results in nobody advocating for them. Another important point according to Psychiatrist Kenneth Appelbaum, is that the American Psychiatry Association does not properly address the ethical challenges that their members who work in prisons face daily (Press, 2016). In other words, there is a lack of engagement in questioning how the mentally ill incarcerated population should be cared for. This lack of engagement is certainly a reflection of the elitism in the profession, that is, many professionals belittle the work developed in prisons.

Personal Reflection. In the beginning of the paper, I intended to discuss the evolution of the treatment of the mentally ill in the United States. However, as my research advanced and as I narrowed my subject of analysis to the prison system, I concluded that, despite historical advocacy, there was no evolution and that inhumane treatment continues to happen in different ways. Even though our society knows of the existence of human rights, the culture of human rights is far from implemented and internalized by individuals. Instead, I learned that there is the culture of fear and the culture of “it’s none of my business” inside prisons.

Jimenez (2010), sheds some light on the concept of ideology as “templates, or reassuring explanatory structures that can explain contingencies, both the unexpected and the taken-for- granted aspects of social order” (p.45). Community, government and the media exert considerable influence on the formation of the individuals’ ideologies. That said, the beliefs of upward income mobility and equal opportunity are, according to Jimenez (2010), ideological positions aimed at promoting social control and quieting feelings of social unrest (p.60). That was a reality in the 19th century and continues to be nowadays. An interesting example is immigration; the image sold in countries such as Brazil, is that the United States offers equal professional growth opportunities to everybody who works hard. Therefore, people want to come here and pursue the American dream, nonetheless, when they arrive in the country, they start facing social barriers. The thought of a completely open social and economic order and the association of economic success with individual merit does not correspond to the reality of many immigrants who are educated but when applying for a job, face unfair situations such as the other candidate’s personal connections, favoritism and ethnic discrimination.

The ideas of upward income mobility and equal opportunity prevalent in the U.S society tend to hinder the development of individuals’ critical thinking about inequality and lack of economic opportunities (Jimenez, p.61). In other words, if everybody believes that their social condition is only temporary and that their personal success is solely influenced by their own choices and not external factors such as the political environment, there is no reason for people to fight for better social conditions or even to fight for a complete change in the economic and social systems of government. Jimenez (2010), further clarifies that it is unlikely that most people will criticize ongoing poverty and oppression in the United States due to the lack of a major political party leading a critique of the market’s economy (p.77). In the 19th Century, Socialist political traditions were a reaction against industrial capitalism’s ways of exploiting workers in England and Germany (http://public.wsu.edu/~brians/hum_303/socialism.html). Nonetheless, in the U.S, the myths of upward mobility and equal opportunity kept society optimistic and working hard on pursuing the American dream, if not for them, for their next generations.

The view of social work as a means of social control presented by McLaughlin in the article “Social Work’s Legacy: Irreconcilable Differences?” is an eye-opener to those new to the field of social work. According to the author, critics affirm that the mission of social work is no longer to help the poor and oppressed, but to control them, utilizing psychotherapy as a method of intervention (p.188). Interestingly, if one compares social work in the United States and social work in Brazil, one will realize that in Brazil the scope of social work does not include the clinical aspect. In other words, psychologists and psychiatrists will work in the mental health field, while social workers will address social justice issues at collective and individual levels. Perhaps, the Brazilian approach to social work would be more in alignment with scholars such as Spechat and Courtney, however, McLaughlin (2002), urges social workers to think reflectively about the betterment of the individual and the betterment of society as complementing each other (p.196-197).

Day (1981) in the article “Social Welfare: Context for Social Control”, shed some light on how social workers and human services organizations might control vulnerable communities and individuals. The author explains that “social workers are generally unaware of the extent of their control and most of them enter the human service field from feelings of caring” (p.30). Day (1981) corroborate McLaughlin’s thoughts on the importance of developing critical thinking about social work as a means of social control, so that social workers don’t become agents of such control, supporting and legitimating it (p.31). Historically, some of the ways social welfare exerted control over society was through the Statute of Laborer in 1349, in which people were kept in certain areas of work to economically benefit others; The War on Poverty in 1965, aiming at controlling civil disorder started by the disadvantaged; and the expansion of Community Mental Health Acts, which had the objective of quieting political unrest in the 1960s (p.32). The author does not deny the usefulness of such programs nor the unselfish feelings of people working for them, however, he emphasizes what he calls “the programs’ latent functions; public intrusion into private lives, expanding definitions of deviance and new pressures for and legitimation of conformity” (p.33).

Other important ways in which social workers and human services agencies exert control over society are through values, attitudes and the power relations. Day (1981) exemplifies human services organizations as symbols of power, in which the social worker is the expert and the client is the one seeking for help. One can imply that the client is inadequate and needs to be taught how to meet society’s standards of functioning (p.34). If not carefully observed, the power relation might translate into social workers adopting the position of experts and disregarding the client’s abilities, knowledge and rights.

References:

Day, P. (1981). Social Welfare: Context for Social Control. The Journal of Sociology & Social Welfare,8(1), 29-44. Retrieved January 6, 2016.